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the question is, where is the sugar, in what foods? all of them. one third of the sugar we consume is and beverages. are we know about those. 1/6, desserts.

candy, ice cream. that means fully one half of the foods that have sugar we didn't know had sugar, like salad dressing, yogurt, tomato sauce, ketchup, crackers, other carbohydrate products, all things we didn't know. does anybody like wheat thins? check it out. [laughter] and next, they say, we were wrong about fat. we all said, fat was bad, and now you are telling me, it is sugar. what makes you think you are right now? we need more research. indeed, we do. we absolutely need more research. i don't argue that. do you know what that is called? that is called the pessimistic meta-induction theory. look it up on wikipedia. this says that whatever we thought 10 years ago is already wrong and whatever we think today will be wrong 10 years from now. true. i have seen these cycles come and go in medicine.

the question is, why should we do anything if everything is going to be wrong anyway? why should we change anything? do you know what that is? that is moving the goalposts. that means we will never do anything. it means we might as will stick with the dogma of the day, because everything will be wrong. ask galileo. that is what they wanted to do with him. the question is, what level of proof do we need in order to make change? that is the arugment today. how much do you need to know? i agree, correlational data is not good enough. you do not know directionality. you have questions about multivariate versus univariate and other things that are going on. but when you have causal, medical inference, which is what you have with sugar and diabetes, that is exactly what we had with tobacco and lung cancer in the 1960's, and it is still all we have.

we have never done a scientific proof experiment, because you would have to take naïve people and start them smoking for 50 years. that is in unethical, immoral, and too expensive. 90% of what we know today in medicine today is causal medical inference. only 10% is scientific proof. but the food industry says we need scientific proof to make any change. why? because they know we will never get it. finally, regulation is tantamount to the nanny state, like michael bloomberg, the nanny. that fact is, we have already been told what to eat. it is too late. everyone says, keep your hands out of my kitchen. fact is, your kitchen has already been invaded and you have already been told what to eat. of the 600,000 items in the american supermarket, 80% have added sugar. added by the food industry for their own purposes, not for yours.

you've already been told what to eat. this is not about big brother. big brother is here. so the big question is -- who do you want in your kitchen? do you want government, who will take your money and your freedom? or do you want the food industry, who has already taken your money, your freedom, and your health? that is your choice. everything else is a false choice. and the question is -- how does the food industry stay where they are? well, this is published by michelle simon, a former graduate of uc-hastings, and a former research associate. and now a word from our sponsor. and a-n-d is very specific -- academy of nutrition and dietetics. are america's nutrition professionals in the pocket of big food? that is who is paying their bill. how about this? co-opting health professionals.

i give a talk at the american academy of pediatrics in october, 2009, and i had this slide. and the american academy of pediatrics said if you show the slide, we will not let you on the dais. i had to take it out, but i'm showing it now. here is what has happened to our food dollars. 1982, 30 years ago, 2012. meat down 10%, because we were told to go low-fat. fruits and vegetables exactly the same. everyone tells us, we need to get more. we are eating all the fruits and vegetables we can. grains and baked goods. up 1%. not even a big deal. dairy products down from 13% to 10% because we are all lactose intolerant. finally, processed foods and sweets. 11.6% to 22.9%, a doubling in 30 years.

that is where the money went. that is what you are paying for, and that is what is causing the chronic metabolic disease you're looking at. and this is a war, because what is good for them is bad for us. what's good for us is bad for them. there is no middle ground. it's a war. the question is -- who's winning? here is the stock price of the s&p 500 against mcdonald's, coke, and pepsi for the last five years. here is the economic downturn of 2008. mcdonald's, coke and pepsi are doing quite well, thank you. and here is monsanto, hormel, adm, general mills, con agra, procter and gamble, kraft, they are all doing better than the s&p. if you want to make money, invest in a food company because they have a winning formula. they have a formula that cannot miss, because it is legal and addictive. the problem is, we are all dying in the process.

so this paper just came out a couple of months ago in lancet. profits and pandemics. the prevention of harmful effects of tobacco, alcohol, and ultra-processed food. they make the argument, and i subscribe to this, that we use to practice old medicine which was about infections. and the vector was microbes. that is what i learned. now the new medicine is something else entirely. it is about chronic disease and the vector is multinational corporations who have figured out how to game the system. now, what are we going to do about it? this is a public health problem, and that means we need a public health solution. take a look at all of these diseases. every disease on this list was a personal responsibility issue before the sheer gravity of the problem made it a public health crisis. as we talked about hiv, as an example. how about guns? is that a public health problem?

except that it is a personal responsibility problem, isn't it? depends who you ask. if you asked the supreme court, it is a personal responsibility problem. but it's not. it is a public health problem. and i would put sugar right down there as well. so here we have with the government is doing right now. it is called the let's move campaign. michelle obama's campaign to try to reduce obesity in a generation. what she says his focus on individual, focus on the family, and focus on the community. but she leaves government and the food industry out. now, anybody remember her very first speech after let's move was rolled out in 2010? it was to the grocery manufacturers association of america. and she pointed directly at them, just as i am to you right now, and said, this is your fault. you see this on youtube.

this is your fault, and you have to come up with a solution. she never said it again. not once. why is that? why? she's been muzzled by her own administration because they do not want this fight. and i know they do not want this fight because they told me they do not want this fight. sam caste is michelle obama's personal chef and her point person to her obesity task force, and he told me after reading the new york times article, everyone including the president said they are in agreement and they will do nothing about it, not a wink, not a nod, because they have enough enemies. that is what this is about. and you'll notice, anita dunn who founded let's move now lobbies for the food industry. and now a word from our sponsors. the question i will leave you with -- can our food environment to change without government or societal intervention, especially for potentially addictive substances?

did just say no work? does education work for substances of abuse? the answer is no. question two -- can we afford to wait when health care will be bankrupted to chronic metabolic disease? we have got 13 years, people, and we have to do something now. not wait for more research. we have the research. we have what we need. policy what do we do? there is called targeted prevention. that is treat the patient, right? treat the obese person. except for one thing. we've just learned that there are more nonobese people who are sick. it is targeted to the individual. the benefit to risk ratio is high.

the weaknesses is the medicalization of prevention, which is hard. behavior medication, which is impossible. cost feasibility and limited success across the board. but it is not targeted. it is public health prevention we need. what are the strengths there? it is radical. it is going to work because we will make it work. it's powerful, because everyone is onboard. environmental modification, fix the environment, not fixed behavior. that is what our data show about obesity, fix the environment. the limitations are the libertarians, -- limitations of acceptability, the feasibility, and cost. what can we do? we could tax and restrict access and intervene. i am not suggesting we intervene. we tried that with alcohol. it was a disaster. you cannot have storm troopers invading people's homes for baking an apple pie.

that is not going to happen. i do not even suggest it. because my wife would be the first one they would have to take away. what we need to do, like we have with every other substantive abuse is come to peaceful coexistence. we have to find the right amount of legislation, regulation to be able to manage the problem rationally, like we tried to do with tobacco. we can argue about the wisdom of that, especially worldwide, and alcohol. no interdiction but plenty of taxation and restriction of access as needed. so what factors contribute to increased soft drink consumption? price. since the 1980's, the price has and the introduction of high fructose corn syrup, the price has only increased 50% versus food. food has gone up higher than sodas have. sodas increased only 20% against fruits and vegetables. we are supposed to be eating fruits and vegetables.

sodas are cheap and fruits and vegetables keep going up because they are not subsidized. we've allow the serving size to rise. in most developing nations, soda is cheaper and safer than water. until potable water is cheaper than soda, we cannot solve this global health crisis. i totally agree with that. access. what is available worldwide, especially in schools. 50% of flavored milk, that is chocolate milk, is available in schools. and marketing. in 2006, food marketer spent $1.05 billion to marketing, half for soda, to children and adolescents. the question is -- our children a rational target? is that acceptable?

why is alcohol so relevant to this question? i think the analogies between sugar and alcohol are very strong. and we should look to alcohol control policy. and my colleague and i and allen taylor, a visiting professor at georgetown, are planning to write a book on exactly this shortly. both are nutrients, but aside from energy they have no health value. metabolic and central pathways in the brain are similar. both are substances that produce when overused. there is little danger from moderate consumption. the problem is what is moderate and how do you keep things moderate when they are abused? and the burden of harm falls disproportionately on the poorest people who can afford the problem least. here are the strategies that have actually been shown not to work. governmental guidelines are useless. we keep saying, let's come up with new guidelines, like every five years. like the dietary guidelines

advisory committee. it is garbage. it is not going to work. public information campaigns have not worked. warning labels on product packaging have not worked. vis a vis smoking. school-based education programs. everyone wants this to work. everybody says, let's put the money into school-based education. all the data so far shows salutary effects almost nonexistent. menu labeling. everyone says, let everyone know what they are eating so you can decide for yourself. let's look at menu labeling. i like this one. here is the adult menu labeling study in new york city. a historical, cross-sectional study. we had data before labeling and after. what happened? nothing. nothing happened. mean calories did not change. they went up. three major changes showed very small decreases.

15% of the respondents reported using the caloric information, and those that did purchase 106 fewer calories than those that did not, but that is all most none of them, because when you go into a fast food restaurant, you were going for taste, and they say so. they may say they're going in for salad, but they buy the burger and fries. and there is a reason for that. children. 349 children and adolescents, most accompanied by their parents, and most from racial minority groups, no significant differences in calories purchased before after labeling. 35% ate fast food six or more times per week. 57% noted the labels. but only 9% reported using the information indeed. and 72% reported that taste was the most important factor. do you think that knowing what is in your food changes what you eat?

not at all. so, education. how are we going to do that? which nutrients will we educate people about? you think the total fat on the label actually matters, because there are good fats and bad fats and they are all crushed in together. how are you supposed to know? what about salt. we have had long discussions about salt and whether or not salt matters in the american diet. what is the target and what is the message? if it is about total calories, we are sunk. we will never get past this. that is what we have done for 30 years. the definition of insanity is doing the same thing over and over again and expecting a different result. we have done the same thing over and over again for the last 30 years. somehow, somebody in washington still expects a different result. good luck. food labeling. add sugar content.

could we put the number of teaspoons in teaspoons on the front of the label and would it matter? maybe labeling has not worked in new york city. education alone has not worked for any other substance abuse. why would you think this would be enough? i think it is necessary. i think people need to know what they are consuming, but it is not sufficient. necessary but not sufficient. what about strategies that might work? controls on advertising and marketing have been talked about. counter advertising campaigns. anyone ever see new york city's man drinking fat commercial. it is on youtube. it is disgusting. it is fantastic. i love it. and it has not changed soda consumption in new york city at all. finally, industry self- regulation. really? in 2007 in istanbul, 52 european health ministers got together and agreed that we needed to cease marketing of junk food to children. i agree. i approached the fcc director under george w. bush with this exact same issue after this meeting had occurred, and she

said "i expect the food industry to police itself," which is exactly what they have been doing all this time. it is hands off. the food industry -- hands off. the corn refiners association, you may remember last year, they tried to rebrand hfcs as corn sugar and the fda told him no. they have done it anyway. you know what? they will get away with it. why? because the fda does not have an enforcement arm. the enforcement arm is the department of justice. they got better things to do. they do drones and other things. how about on a community level? santa clara and san francisco in 2010 instituted the toy ban? why should you coerce a child into buying a happy meal for the toy.

let's disassociate the two. if you want the toy, by the toy. makes perfect sense. well, since then three states have banned toy bans. not really getting rid of that. i don't know why it does that. let's go back. ok. and finally, the campaign to retire ronald. which is ever continuing. how about things that are likely to work? pricing strategies are likely to work because people care about price. controls at the point of sales. bundling strategies. government agency action. those are the things that will work. those of the things that worked in the past. the problem is you need people on board. you need government on board in order to be able to enact those. let's talk about pricing. soda taxes. canada and europe already do this. they have the general services tax, the value added tax. the price elasticity on a can of soda as very small.

price elasticity is how much of a change in consumption you will see with the one percent change in price. it does not change much. a 10% price increase only increases consumption by 2%. that is not very good. that is what we talk about -- a penny an ounce. existing taxes on soda so far have not resulted in soda consumption. at 3%. this fits this. soda taxes, are they for programs or to reduce consumption? if they are for programs and not consumption, do you know what will happen? soda companies will say, it did not work. worse yet, some unscrupulous politician will take the money and use it for general funds or personal funds and that is what everybody is worried about because that is what we have seen already with tobacco.

large taxes are necessary to reduce consumption. the rand corporation says we need a 36% tax to effectuate a 25% reduction in consumption. we need to double the price of a can of soda. do you think anybody is ready for that? where should we tax the ingredient instead of the product? should we tax the sugar before it goes into the food, rather then tax the food itself? the problem is you would need that to be national. you would need congress to do that. only they can levy such taxes. you could not do that state-by- state because of commerce clause. finally, restriction, controls on the point of access. age limits. maybe we should card kids for coke. if their parent wants their kid to have a coke, let them buy it for them. and that would cost nothing. we could do that tomorrow. we do that for beer. zoning controls over the number of sales. why is there a convenience store within 500 feet of every single

school in america? because the kids are target. and they know it. how about use permits that control hours of operation? maybe they cannot sell soda between 7:00 and 9:00 in the morning at 3:00 and 5:00 in the afternoon when kids are coming to and from school. we have said is out of school in california, we had sb19, in the last study said that obesity rates are stable. maybe it is because of this, we do not know. and there is the big gulp ban that was struck down as arbitrary and capricious by the appellate court in new york state. citing a case in 1986, boreali v. axelrod. this case was about public smoking. the thing was it was 1986. in 1990, we learned about secondhand smoke. if boreali have been decided four years later, there was no

way it would've been decided in this fashion. we have the secondhand smoke of obesity and sugar consumption. it is called health care disaster. the fact is, using boreali as a reason to strike it down made no sense. this would ultimately be appealed to the new york state supreme court. here's what happened to sugar sweetened beverage access within schools. you can see it here in terms of purchasing in sixth and eighth grades. look at the arrows. in the schools where sugar sweetened beverage sales have gone down, sales have gone down. that is great, except for one thing. here is the total consumption -- it has not changed. why? they get it on the way home or at home. until we change the entire food environment, concentrating on schools is not going to work.

how about bundling. how about differentials differential subsidization. why can't we tax the bad food and subsidize the good food? could we subsidize broccoli, so that it would be in the best interest of the food industry to promulgate it. we could modify behavior through pricing. we always do. the nordic countries have subsidized low alcohol beers and taxed hard spirits in an attempt to solve alcohol problems. they have been successful in terms of car accidents and cirrhosis of the liver. they have done this over 30 years. differential subsidization. we could discount diet soda and tax sugar soda. i am not sure that diet soda is any better, but it sure is not a whole lot worse. this is the thing to remember. the iron law of alcohol policy says reducing the availability of alcohol will reduce alcohol consumption and reduce alcohol- related health harms.

the same holds for sugar. the problem is -- how do you get there? how about government agency action. regulation in the food industry by congress is a nonstarter. they are not touching this. there is no way in the world anyone in congress will go out on a limb for this. but why can't the farm bill subsidize real food instead of food ingredients? that is what it used to do. food stamps. bloomberg try to remove food stamps from snap and he was rebuffed by the usda because the usda is in the pocket of the food industry. several other states have applied and the usda has rebuffed them. but the question is why is the usda in charge anyway? that is like the fox in charge of the hen house. the usda sells food, it is hhs's job to keep us healthy. shouldn't this be an issue for them? not an fda issue. the efsa, the european food

safety administration, could influence the court of public opinion to make sugar less appealing. cigarettes went from fashion to filthy habit in a few years when people got on board that there was a problem. the fda could revisit the nutrition labeling education act. instead of total contents, labeling should reflect the degree of processing of the food. so what was added and taken away because all food is inherently good. it is what we do to the food that is not. if we add something, that is a problem. if we take something away, that is a problem. tell us what you did to the food instead of what is in the carton. if we did that, breakfast cereal would disappear. gone. the fta could re-examine their 1986 grasdetermination. generally regarded as safe. one of the reason we're in this mess is because sugar is generally regarded as safe. this is something determined in

1958 with no data. the results were inconclusive in 1986 that a mean dosage of 50 grams per day. our current dosage is 80 grams per day. we did not do it at that dose. and the issue with -- is intended use. no one intended for sugar consumption to be this high. the sugar industry took that information and so the government gave them a clean bill of health when it was only inconclusive. there are lots of problems with this document. it was based on a 1978 survey at 53 grams, no data on excessive consumption. no data on high fructose corn syrup back then. and fruit juice was considered fruit, not sugar, which it is. so who knows what the real story is? that this is what the 1986 document said, and the person who wrote that document is now a consultant to the corn refiners

association. and there is no dietary reference intake for sugar. there is the nutrition facts label. there is a percent daily value for everything. nothing for sugar. it is not listed. why? sam cast said, why would you need a dri for something that is not a nutrient? something that is not a nutrient? he is actually right, because sugar provides no nutrition. it only provides energy. you do not need sugar to live. there are people who have the disorder in their liver called hereditary fructose intolerance. if they consume sugar, they die. we figured these patients out when they're six months old when they get their first dose of juice, and to become hypoglycemic down to 5. and they are sugar free for the rest of their lives. and they are the healthiest people on the planet and they consume no sugar. why? because sugar is not a nutrient.

it is an energy source, but it is not a nutrient. is alcohol a nutrient? yes or no? supplies calories. but is it a nutrient. it is a toxin and we treat it as such. same thing here. how about legislative options, advocacy, attempt to apply pressure on the government? good luck. center for science in the public interest is doing that, but nothing has happened so far. legislation has a very long on- ramp. it takes a long time to make anybody do anything in congress. and part of that is due to corporate lobbying. other strategies, so far nothing. how about the farm bill? price subsidies create market distortion. it would be much better to get rid of all the subsidies and let every foodstuff reach it's appropriate market capitalization. that would work nicely. the problem is, the food industry would have a cow.

the question is -- is that ok? is it ok for the food industry to have a cow? i think it is. finally, legal actions. this is the statement that got me to law school. the hyderabad statement. from an indian public health for. all significant advances in public health require and involve the use of law. when i heard that, i went, yes. that is exactly right. and that is why i came to hastings to get my masters. much shorter on-ramp. you can actually make something happen. you can do regulation through litigation. it is the most bang for your buck if you have court support. first question -- who is the defendant? is it the corn refiners or any sugar producer or is it the distributors and the and manufacturers? hard to know. that is a big question.

many companies -- theories to ascribe culpability -- market share, coke would pay for 29% of the diabetes in the world. take responsibility for a contribution to edit sugar in the environment. these are questions yet to be answered. would you do this to individual plaintiffs or at the state or federal level? they were not successful against tobacco. 845 individual actions brought against big tobacco. only two were successful and both were overturned on appeal. how do you think this would go with something like sugar? it would be even harder. there are so many different defendants. how about class-actions? they were great idea until at&t mobility v. concepcion which said the supreme court does not want to hear these cases anymore. they are not interested, but but there are still 12 states that have this. misbranding is going on in the superior court of california because there are 56 names for sugar and total sugars are on

the label not added sugar. which is what we need. what about liability. this is a big question. is soda a defective product? what do you think? if used as directed, does it kill you? yes or no? what do you think? 11 fold increase in diabetes. what do you think? yes or no? other products contain nutrients, so they would be unlikely to be considered defective. but soda. ain't nothing in the soda you need. everything in it is something you do not. and finally, failure to warn. it turns out latinos are susceptible to this. and they get the worst nonalcoholic fatty liver disease and the worst incidence of diabetes. 50% of california latinos get diabetes. they have a genetic polymorphism that makes their liver

susceptible. they need a warning label on every can of soda, saying, latinos, you will get sick from this, because they will and they do. and i have to take care of them. so where is the label? and finally, the parents parens patriae. the state is the parent. how the mississippi attorney general sued big tobacco. because the state is more than a nominal party. they stand to lose big. they are losing $1.5 billion for diabetes and the state of california every year. there is no requirement for tort liability. all you have to do is show the economic harm. and the state is not a nominal party, which is easy to do. we could recoup medicaid for diabetes and other diseases as well. all sorts of academic papers and more academic papers. and then non-academic.

fat chance, which you can purchase today. this will be out in six days. an e-book that people can use to go into the store and use it to shop properly because it lists the added sugar in each food in the supermarket. and finally, in january, we will be releasing the cookbook. in order to turn this around, people have to learn how to cook again. the question is -- how do they do that and what is it they will make and how do they do it fast? everyone one of these recipes was vetted by a high school student. if they can make it, so can you. and they are good. lastly, we have started a nonprofit organization to provide medical nutritional and legal analysis and consultation to promote personal and public health versus big food.

institute for responsible nutrition. responsiblefoods.org. come join, sign up. we will let you know what is going on and you can contact me for more information. i want to thank all of my collaborators at uc-hastings. in particular, david, marcia, john diamond, pat davidson, and my colleague who did the heavy lifting on the statistics on the diabetes study. and kristin kerns who is the person who is basically doing the sugar documents in the same way as the tobacco documents. and stan, who is mr. anti- tobacco, and has realized that noncommunicable disease whatever it be is the problem of the 21st-century. we need to solve it, and we're going to need all of you in the room to get on board and help us do it. with that, i want to thank you

all and i would be happy to answer questions. [applause] >> if you have questions, if you make your way over to the microphone and introduce yourself. >> i answered everyone's questions? that is pretty bad. happy to answer any questions. >> hi. >> go ahead. you bet. >> many questions. try to limit to a couple. so the last, the last piece of information you shared with

regards to latinos and a higher likelihood of metabolic disease given exposure. i wonder if you could talk a little bit more about what we know about that, or where we could find more information about that. we do have a community group here in san francisco interested in health equities impacting latino community, who want more information with regards to that. >> i gave a talk two years ago at the latino health forum on this question. it is a huge problem, especially in san francisco. what we know is that sugar gets converted to liver fat but there are certain things that go on in the liver that can make that worse. there is a gene, pnpla3, it is a gene. and if you have certain polymorphism, which 19% of

latinos have, 19%, a little sugar makes a lot of liver fat. way more than if you have heterozygous or homozygous for the wild type. in addition, there is another polymorphism for another gene, which is one of the molecules that helps the mitochondrial function properly. if you have a polymorphism in that, which latinos carry, you are not going to be able to put enough energy through the mitochondria, which means the backup will get turned into liver fat as well. so both of these are known risk factors for developing nonalcoholic fatty liver disease which is a cause of type 2 diabetes, and latinos are susceptible. the point is that latinos of all ethnicities have to be careful about their sugar consumption. the fact is that latinos are the least careful about the sugar consumption.

they do not even drink water. they drink aqua fresca. they have more names for sugared beverages in spanish than virtually there are in english. and i have actually compose a list of those and published it in the journal of pediatric nutrition in 2012. it is pretty ridiculous. [speaking spanish] the list goes on. it is pretty astounding. kids, they tell us, they drink it because it tastes good. yeah, i know. but this does not mean it is good for you. and we have a real hard time convincing parents, latino parents, of the hazards of this practice. so we have a lot of work to do. >> thank you. i hope there are folks working on that locally. we have a lot of work to do. one more question, since there is not anyone else at the

microphone yet. my name is roberto vargas, i work at the clinical and translational science community and health science program at ucsf. with regards to differential prices, you pointed to the example in nordic countries. subsidization of -- subsidizing beer, heavy taxes on alcohol. do we have any other examples of that? has there been any testing of that with regards to sugar beverages? >> no, there has been no testing. not that i know of. what i can say is that there is one study out of harvard where they change the price in the hospital cafeteria to see whether or not they could get people off sugar sweetened beverages. they had to change the price to to change the price significantly.

we are about to embark on the study at ucsf that the head of food services is the principal investigator on, where we will try to do the same thing in a hospital setting, which is very different than the general setting. but hospitals have to start this. the bottom line is -- it used to be the people smoked in hospitals. and now they do not. in fact, hospitals were the first place is to ban smoking entirely. and we will probably have to be the first phase is to ban sugar sweetened beverages entirely, too. >> hi. can you just say a little, a few words about the reversibility of the condition? for instance, what is the duration of exposure for a child at risk? let's say they stop their soda consumption when they turn into, the age of 20, smokers will ultimately go back to the risk for lung cancer over many years.

what happens to children -- >> there are two issues. there is the nonalcoholic fatty liver disease and the diabetes issue. the nonalcoholic fatty liver disease issue, if it is just fatty liver, it is eminently reversible. it can take time, but it is reversible. we are doing a study at ucsf where we are isocalorically taking sugar away and substituting complex carbohydrates for 10 days. i am blinded to the results, so i cannot give you the answer to that, but we anticipate that we will reverse their fatty liver disease during that time, because we have data in adults that 14 days of doing the same thing was effective. 38% reduction in liver fat during that time. if -- sorry? >> what is the duration of exposure that would bring about fatty liver and the child? >> two weeks. two weeks.

heavy drinking -- >> of soda. >> and you get it in alcohol, too. three sodas a day will get you there. in terms of the scarring that occurs, the cirrhosis. once that occurs, that never gets better. once you go from fatty liver to fatty liver plus inflammation, that never improves. five percent of the patients with fatty liver go on to develop cirrhosis over time. you can slow it down by getting rid of the substrate and by using antioxidants, but it is a progressive lesion from that point on, which will ultimately kill you or require a liver transplant. now diabetes is eminently reversible. type ii diabetes is reversible in most patients. problem is, not with our current diet.

but people who go on the paleo diet see all of the medications go, they do not need their medications with in 8 weeks of starting the diet. once they actually change their diet and their composition. so i think that diabetes is eminently reversible. if you do the right thing. >> dr. lustig, what is the role of ethnic communities, what plans do you have for translations in other languages to be able to make it accessible? >> the thing i am most upset about is that there is no spanish version of fat chance. if anybody here is a spanish- language publisher, come talk to me. we have tried to get various

publishers interested in in publishing a spanish-language version. and there are all sorts of problems with that. it is in norway, slovenia, turkey. it is in new zealand, in korea. it is in the u.k. and australia. but that is in english. it is in a lot of countries. it is not in latin america and not in mexico. and the reason is because no spanish language publisher has picked it up and i cannot tell you why. i cannot publish the book, it is copyright, i cannot publish the book myself. that would be really good. we have all sorts of materials that we hand out in our clinic that are in spanish language, very specifically because that is the audience that needs it. we worked very hard to make sure that they get the message. the bottom line is, we do not go home with them.

they ultimately do what they do. we do the best we can. education has never fixed any substance of abuse. >> thank you very much, dr. lustig. the last comment you made, education not fixing an addiction abuse situation. in a stressful society, sugar serves a role. it is comforting, it triggers dopamine. so i am curious about that. is there any possibility of creating -- if you take something away, what will you give them? >> this is like the holy grail. the $64,000 question. if you take something away that gives pleasure, while they search for something else pleasurable instead? could it be that they substitute something even more dangerous in its place? they go back to smoking, they go to cocaine. these are very concerning. these are worrisome issues.

i do not know the answer. i do know that something has to be done because we cannot afford health care associated with this. this is an unsustainable model. if you think about what happened with tobacco, let's talk about tobacco for a minute as sort of the flip side. when did smokers die? average age, 64. that is what the actuarial analysis says. the average age was 64. do you know what happens at 64? you pay in to medicare and pay into social security. and you die. and you do not get anything out. this is actually a sustainable model. in addition, when you got lung cancer, how long did you have before you were dead?

6 months. how much money could you spend out of your health care dollars in six months of lung cancer? not that much. so, you paid in. you did not get out, and you did not cost society a whole lot. now, we do not smoke. or we have cut down smoking at least by half. so what are we doing instead? addiction transfer. we have chosen an addiction which seems safe, except that it is not. and worse yet, it is causing adolescent type 2 diabetes. and these patients are going to be sick for 20, 30, 40 years before they are dead, and their productivity is going to be nil. and they are going to chew through all of the health care resources of this country and they are not going to be productive. they are going to be on the dole, because they will not be able to work.

so the question is -- is this a better model than what we had before? what i say is, let's get everybody smoking again. [laughter] i say that tongue-in-cheek. >> you said that education alone would not work, but maybe a pricing policy or something more hard, plus an educational model. >> absolutely. for every substance of abuse, we have needed both personal intervention, which for lack of a better word, we can call rehab, and we need societal intervention which we can call laws. for every substance of abuse, we have needed both. rehab and laws. that is what we had for alcohol and nicotine and for cocaine. that is what we have for heroin, etc. for sugar, which meets all the criteria, we have nothing. so the question is, how are we going to do that in order to salvage our health care system? that is the big question. your point is absolutely -- the

holy grail. what is going to happen if you reduce sugar consumption? if that is a matter of pleasure. one thing on that subject. do you remember tolerance? down regulation of the dopamine interception? if you reduce consumption, what happens to that dopamine receptors? they go back up. you get more pleasure. we could find a peaceful coexistence with sugar that would ultimately provide the pleasure and still keep our health care costs down. i say the answer to that is assuredly yes. >> so what is the nature of pleasure? oxytocin is, how do we substitute goes to create behavioral states. and training that is a societal issue. the anatomy and physiology of medicine but also law.

what is responsibility? what is self generation of behavior? from a legal perspective. >> this is the new ethics of health care. is how do you balance personal responsibility against societal needs? and that is i why went to law school was for exactly that. public health law. jacobson v. massachusetts, 1905. there was a pastor in cambridge who refuse to get vaccinated for smallpox. said it was a religious objection. the supreme court said, too bad. you live here, you are getting vaccinated. tough luck. the bottom line is there is a point at which every person responsibility issue becomes a public health one. and the question is -- where is the line and what are the legal doctrines that govern the crossing over of that line? i would submit to you that we have surpassed that for this

problem. yet we have not enacted any societal interventions that are meaningful to try to fix it. that is what needs to change. >> thank you, dr. lustig. i was wondering if you could speak little bit to other disease in addition to obesity, such as autoimmune disease. >> autoimmune disease is a grab bag. this is being televised, taped. and i am about the science. the science on auto immune disease is very much an open question. so i am a little loathe to tell you how all of this might tie into autoimmune disease, other than to say that people are working on it. i am very interested, but i am not willing to go public on it.

not until we have hard science. so i'm going to have to beg the question right now. sorry. >> dr. lustig, i just wanted to make one brief comment about the idea of if you are taking something away, what are you giving? if you take away sugar, what is the reward? >> i have never said take it away. >> reduce exposure. >> reduce availability. to a manageable level. i never said take it away. a lot of people say i say that, but i have never said that. do not put words in my mouth. >> if we reduce the exposure to added sugars, in a very small sample size, mostly middle-aged midwesterners in the united states, i can say one of the main rewards that these people are getting in a health education program i am running on this topic is reduction, and when you reduce your waistline circumference, people start to notice and you start getting a lot of compliments.

and people respond to that. and it keeps them going. i know it is not the only answer, but behavior modification is one piece when people start to be rewarded by observation. and i can speak from being a midwesterner myself and seeing a lot of people in this area of the country and this age group specifically respond very well to that. >> i do not disagree with you at all. my mother had a famous saying -- a minute on your lips, forever on your hips. i got that a long time ago. still, that is the way it goes. the bottom line is -- you can only change your behavior if the environment allows for it. when 600,000 food items have 80% adulteration by added sugar, it is awfully hard to change her behavior in a toxic environment.

the toxic environment has to improve in order for you to be able to manifest those changes in behavior. that is what i would say. >> and to sustain them over time. that is all, thank you. >> that is all the time we have. i would like to remind you -- rob will stick around a little bit to sign his book. finally, i would like to thank him. >> thank you. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> saturday was the deadline set by the obama administration for necessary fixes to the health

care website. sunday, reporters were briefed by phone about the progress being made. it was mid-october, when he was named to oversee changes to the site. here is some of the conversation. it is critical that the result -- that we doubled the system's capacity to now support its intended volumes. [indiscernible] simultaneous users at one time. we know that each user spends an average of 30 minutes on the site. the site will support more than

800,000 consumer visits per day. there will be times that this increased capacity will not be sufficient to happen -- handle peak demand. times, we for those will deploy a new system to serve consumers in an orderly fashion and allow consumers to request e-mail notifications when it is a better time to come back to the site. span, we bring public affairs events from washington directly to you, putting you in the room at congressional hearings, white house events, briefings, and conferences. offering gavel-to-gavel coverage of the u.s. house as a public service of private industry. created by the cable tv industry 30 years ago and funded by your local cable or satellite provider. you cannot watch us in hd. -- can now watch us in hd.

>> up next, q&a. "washington journal" at 7:00 a.m. eastern. >> this week on q1 day -- q and careercal [indiscernible] >> you did a heart transplant overnight. explain that. [indiscernible]

>> what was the condition of the person you apart from? obviously dead. >> unfortunately, it is always a tragic story. typically a young person because those are the most ideal candidates for organ transplants. motor vehicle accident in this case. that is typically what it is. some common denominator among all of the donors is that they have a brain death. that is what they succumb to and that is when they become candidates for organ donation. in this case, it was a motor vehicle accident, traumatic brain injury and the demise was brain death.

>> secrecy means you can't go too far with this. >> absolutely. we have to protect the privacy not only of the donor and their family, but the recipient as well. it is something that we regard as a very precious gift that the family is offering. the sacrifice of the passing. it is very revered and on the other side, we want to respect the privacy of all of the individuals. >> without getting into specifics, go back to how this all started for you. where were you when you got a call? >> that is a good question. i was at home. i was about to take my son to scouts. he had a cub scout meeting and we were on our way over there. i was telling my wife, all right, big day tomorrow. you need to get some rest and i will take edmund to scouts.